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ANTENATAL CARE
This chapter defines antenatal care and provides information concerning the following topics:
The initial visit
Periodic visits
Health education for pregnant women
Alarming signs and symptoms
Definition
Antenatal care is a preventive obstetric health care program aimed at optimizing maternal-
fetal outcome through regular monitoring of pregnancy. Antenatal care will help ensure:
Best possible health status for mother and fetus
Early detection and timely referral of high-risk pregnancy,
Education of the mother about:
Physiology of pregnancy
Nutrition
Alarming signs and symptoms
Infant care
Breastfeeding
Child spacing
1
This chapter is taken from Ministry of Health and Population, Arab Republic of Egypt, Basic Essential Obstetric Care: Protocols for
Physicians (Cairo, 2004), chaps. 5 and 6.
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Note: Accurate record keeping is indispensable for the work of antenatal clinics.
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Birth weights
Mode of infant feeding
Date of last labor and last abortion (LL and LA)
Present obstetric history
Symptoms of pregnancy
Symptoms of pre-eclampsia
Symptoms of disease in other organ systems
Fetal movements
Family history:
Diabetes mellitus
Hypertension
Multiple pregnancies
Congenital anomalies
Medical history:
Diseases:
Diabetes mellitus
Hypertension
Urinary tract infections
Heart diseases
Viral infection
Drugs/allergies
Other:
Blood transfusion
Rh incompatibility
X-ray exposure
Surgical history:
Dilation and curettage
Vaginal repair
Cesarean section
Cerclage
Non-Gynecologic operations
Family planning history
Immunization history
Breastfeeding history
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Chapter 6 Antenatal Care and High-risk Pregnancy: ANC
Pelvic ultrasound
Periodic Visits
Record the information obtained at these visits on the Antenatal Care Card.
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Chapter 6 Antenatal Care and High-risk Pregnancy: ANC
Clothing
Should be loose, light, and hanging from shoulders.
Avoid high heels, shoes with thin soles, belts, and corsets.
Dental Care
Have teeth examined twice during pregnancy.
Brush teeth after meals
Tooth extraction is allowed even for pregnant women with rheumatic heart disease if
prophylactic antibiotics are given.
Breast Care
Daily washes to reduce cracking
Massage
Express breast secretion
Open lacteal ducts and sinuses
Nipples
If there is dry secretion, treat with a mixture of glycerin and alcohol.
If retracted, treat by pulling out.
Brassiere (light and not tight) to support heavy breasts
Sexual Activity
To be avoided in pregnant women with threatened abortion, preterm labor, or
antepartum hemorrhage (APH)
Traveling
Allowed when comfortable
In patients with a history of APH or preterm lavor it is better to be avoided.
Baths
Showers are preferable over tub baths.
No vaginal douches are allowed.
Exercise
Exercise should be mild, preferably walking.
Housework, if not overtiring, is allowed.
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Drugs
Avoid all unnecessary drugs during pregnancy.
Minor complaints should be managed without the use of drugs whenever possible, by
reassuring the patient.
Smoking
Smoking leads to spasm of placental blood vessels which can lead to the following:
Fetal anoxia
Low birth weight neonates (LBW)
IUGR
Prematurity
Premature rupture of membranes (PROM)
Placental abruption
Immunization
Live attenuated vaccines are contraindicated.
Any pregnant woman who comes in contact with rubella should be tested for rubella
antibodies.
Tetanus toxoid should be administered to prevent tetanus if the mother has not already
been immunized (See Table 6.1)
Table 6.1 Tetanus toxoid
At first contact, or as soon as possible during pregnancy (better after the first trimester).
TT1
At least four weeks after TT1
TT2
At least 6 months after TT2 or during subsequent visits
TT3
At least 6 months after TT3 or during subsequent visits
TT4
Minimum 1 year after TT4 or during subsequent visits
TT5
Rh-prophylaxis in Rh-negative women who did not produce anti Rh-D antibodies
during pregnancy and who have given birth to an Rh-positive infant: such women
should receive anti Rh-D 300 mcg within 24 hours or at the latest 72 hours
postpartum. This prevents Rh-sensitization of the mother.
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Chapter 6 Antenatal Care and High-risk Pregnancy: ANC
Irradiation
Avoid exposure to irradiation for its teratogenic effect on fetus.
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Combined Management
The following high-risk situations require referral to a higher level of health care facility for
combined clinical management:
Diabetes
Heart disease
Hypertension (pregnancy-induced hypertension and pre-eclampsia and/or eclampsia)
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Advice Action
Explain to client that it’s a normal symptom during the Prescribe vitamin B1 and B6
first months and will disappear spontaneously by the
end of the third month
Reassure client and advise small frequent meals as If needed: Primperan
well as eating light food (i.e., crackers) before getting If severe vomiting: refer to hospital.
out of bed in the morning.
Problem: Persistent vomiting continues and affect the general condition of the client
Advice Action
Hyperemesis gravidarum: Refer to hospital
Problem: Constipation
Advice Action
Increase fluid intake, include fruits and vegetables in Mild laxatives can be prescribed when needed.
the diet
Advice Action
Reassure client and advise concerning personal Exclude premature rupture of membrane.
hygiene.
Advise against vaginal douches, only vulval wash.
Advice Action
Anti acids containing magnesium hydroxide
Advice Action
Advise client to frequently elevate her legs and avoid
standing for long periods of time.
Wear elastic stocking if necessary.
Problem: Hemorrhoids
Advice Action
Application of stringent ointments or suppositories such
as Anusol OR Scheriproct
Avoid constipation or diarrhea.
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Problem: Anemia
Advice Action
Preventive measure: recommend food rich in vitamins, Investigate for parasitic infestation.
iron and folic acid.
Prophylactic dose of iron/folic acid started early where
anemia is prevalent.
Estimate hemoglobin and hematocrit value.
Prescribe iron/folic acid.
If severe anemia, refer to hospital.
Advice Action
Cystitis: Refer to hospital.
Pyelitis: Refer to hospital.
Advice Action
Mild: BP less than 140/90, no oedema, or proteinuria:
Advise rest; avoid excessive salt in diet, and frequent
measurement of blood pressure.
Moderate: BP 140-160/90-100 or severe with Refer to hospital.
symptoms such as headache, blurred vision, or
generalized edema
Advice Action
No vaginal examination.
Refer to the nearest hospital.
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Chapter 6 Antenatal Care and High-risk Pregnancy: ANC
First Visit Booking or Registration: As early as possible in the first trimester before
12 weeks
History Taking Physical Investigation Education and Immunizations
Counseling
Personal history Height and weight Urine analysis When to seek Tetanus toxoid
medical care
Obstetric history Blood pressure Stool analysis for Adequate nutrition
ova and parasites
Family history Fundal level Complete blood Persoanl hygiene
count
Medical history FHS ABO grouping and Dental care
Rh typing
Surgical history Wasserman Breast care
reaction
Complaints Arrange for Exercise
hepatitis B antigen
Arrange for Smoking
Rubella antibody
Arrange for pelvic Counsel for Home
ultrasound Birth
Fill out the
Woman's Health
Card
Schedule next
appointment
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HIGH-RISK PREGNANCY
Introduction
Risk factors are conditions associated with child bearing that may jeopardize maternal or fetal
welfare. There are five major categories:
1. Personal factors
2. Obstetrical history
3. Past health history
4. Family health history
5. Ongoing maternal and/or fetal problems
The following tables describe each of these categories in detail along with the potentially
adverse effects of this condition and actions to be taken in this situation.
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Potentially Adverse
Personal Factors Actions to be Taken
Effects on Pregnancy
Less than 18 years old Unplanned pregnancy Intensive and repetitive health
Poor clinic attendance education during pregnancy
Increased incidence of: Prevention and early diagnosis of
Abortion such adverse effects
IUGR Referral to a higher level health
care facility when indicated
Preterm labor
Pre-eclampsia
More than 35 years old Down syndrome Refer to a higher level health care
Increased incidence of: facility
Pre-eclampsia
IUGR
Fetoplacental dysfunction
Prolonged labor
Incidence of obstructed labor
Lives far from hospital or health Delivery on the way to the hospital Schedule admission early in/before
facility Birth trauma labor
Neonatal asphyxia or hypothermia
Positive consanguinity Congenital malformations Prenatal health education
Repeated/habitual abortion Supplementary counseling
Smoking Increased incidence of Prenatal health education
spontaneous abortion, prematurity, Assessment of fetoplacental
PROM, low birth weight and function
placental abruption
Chronic fetoplacental dysfunction
Long duration of marriage with Anxiety with pregnancy Intensive and repetitive health
infertility and use of ovulatory Multiple pregnancy education
drugs Preterm labor Reassurance via careful prenatal
Increased incidence of ectopic care
pregnancy Rule out multiple or ectopic
pregnancy
Ultrasound
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Previous small for gestational age IUGR Refer to a higher level of health
Chronic fetoplacental dysfunction care facility
Fetal demise
Recurrence of risk factors
Previous large for gestational age Gestational diabetes Prenatal health education
Diabetes mellitus Screen for diabetes
Recurrence of risk factors Serial measurement of fetal weight
Dystocia by ultrasound
Birth trauma Refer to a higher level health care
Excessive weight gain facility when indicated
Polyhydramnios
Previous fetal malformation Congenital anomalies Refer to a higher level of health
Hereditary disorders care facility
Previous spontaneous second (2nd) Persistence of risk factors Refer to a higher level of health
trimester abortion or preterm labor Preterm delivery care facility
Incompetent cervix
Recurrent first trimester abortion Recurrence of risk factors Refer to a higher level of health
care facility
Previous hypertensive disorders Pregnancy-associated hypertension Careful prenatal care
during pregnancy Renal affection Monitor protein in urine
Chronic fetoplacental dysfunction Refer to a higher level health care
IUGR facility if the patient develops
Prematurity hypertension
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Previous cesarean section delivery Dehiscence of the previous scar Refer to a higher level of health
Uterine rupture care facility
Previous retained placenta or Recurrence of the problem Refer to a higher level of health
postpartum hemorrhage care facility
Duration of labor < 4 hours Delivery on the way to the hospital Schedule admission early in/before
Neonatal asphyxia and/or hypoxia labor
Neonatal hypothermia
Postpartum hemorrhage
Previous instrumental delivery Prolonged labor Try to detect the cause
(vacuum extraction or forceps) Obstructed labor Prevention of recurrence
Uterine rupture Arrange for delivery in well-
Cephalopelvic disproportion equipped hospital
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Chronic illness The illness may affect the Refer to a higher level of health
pregnancy or vice versa care facility
Uterine anomalies including Second trimester miscarriage Refer to a higher level of health
uterine fibroid or other pelvic Preterm labor care facility
masses IUGR
Abnormal placentation
Malpresentation
Antepartum and/or postpartum
hemorrhage
Abdominal pain due to fibroid
degeneration
Uterine rupture
Previous myomectomy Uterine rupture Refer to a higher level of health
Abnormal placentation care facility
Antepartum and/or postpartum
hemorrhage
Retained placenta
Previous cerclage Incompetent cervix Refer to a higher level of health
Increased incidence of abortion care facility
Increased incidence of preterm
labor
Previous successful classical repair Difficult delivery Arrange for timely referral to
Soft tissue obstruction hospital preferably 4 weeks before
Ruptured vagina delivery
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Previous successful repair of Increased incidence of recurrence Arrange for timely referral to
fistula hospital preferably 4 weeks before
delivery
Previous blood transfusion Fetomaternal incompatibility Indirect Coombs test
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Unknown last menstrual period Post date Clinical evaluation of gestational age
(LMP) Failure to diagnose IUGR Consider ultrasound
Gait: "Limping" Cephalopelvic disproportion Assess pelvic capacity
Obstructed labor Allow smooth, safe vaginal delivery
otherwise refer to hospital
Color: Pallor Anemia with pregnancy Laboratory evaluation of hemoglobin
IUGR Prenatal health education about diet
Preterm labor Iron supplementation
Maternal length ≤ 150 cm Cephalopelvic disproportion Refer to a higher level of health care
Obstructed and/or prolonged labor facility
Marked varicosities of lower Severe leg pain Prenatal health education to avoid
limbs Increased incidence of vulval and prolonged standing
uterovesical plexus varicosities Advise for leg elevation and elastic
Increased incidence of stocking
hemorrhoids Plan for smooth, safe delivery
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Excess amniotic fluid Postpartum hemorrhage Refer to a higher level health care
Fetal malformations facility
Preterm labor
Maternal respiratory distress
Fetal macrosomia
Diminished amniotic fluid Fetal malformations (renal, Refer to a higher level health care
ureteral, pulmonary hypoplasia) facility
IUGR
Stillbirth
IUFD
Preterm uterine contractions Preterm labor Refer for admission to hospital for
tocolysis and fetal monitoring
Sudden gush of vaginal watery Ruptured membranes prematurely Refer to a higher level of health care
fluid (PROM) facility
Prematurity
Cord prolapse
Maternal infection
(chorioamnionitis)
Fetal infection
IUFD
Stillbirth
Neonatal infection
Hemoglobin < 11 gm Anemia in pregnancy Dietary instructions: iron and folic
IUGR acid supplementation
Prematurity Refer to a higher level of health care
Anemia of the newborn facility if the diagnosis is doubtful
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Rubella exposure Severe fetal damage or death if Test for rubella IgM for any woman
infection occurred during the first exposed to rubella or who has any rash
4 months of pregnancy similar to rubella, unless woman was
Congenital fetal infection (heart previously known to have rubella
damage, cataract, deafness, antibodies present
mental retardation) Counsel on basis of severe damage to
Severe disease during the neonatal the fetus
period (bleeding Consider termination in case of
hepatosplenomegaly, myocarditis, affected fetus
thrombocytopenia) Referral to hospital when indicated
Herpes Spontaneous abortion Refer to a higher level of health care
Generalized flu-like symptoms facility
Reactivation
Neonatal herpes infection
Prematurity
IUGR and IUFD
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